HomeMy WebLinkAboutSeptic Pumping Slip - 991 JOHNSON STREET 5/17/2016 Commonwealth of Massachusetts
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City/Town f .
S item Pumping. Record
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Form 4
DEP has provided this formi for use�by local Boards of Health. Other forms may be'used, but the
information must be substantially the tame as that provided here. Before using.this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left/Right front of house, Left kl .,t ........... o.
Bight side of building, Left/Right front of building,Leff Rigfht ea f b, Left/right Under of house, Left/
Y 9 � house,
building, Under deck
Address
City/rown state Zip Code
2. System Owner:
Name'
Address(if different from location)
Cityfrown ' Stated
F
Telephone Number
B. Pumping Rpcord
1, Date of Pumping Date „w 2. Quantity Pumped; Gallons
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3. Type-of s Y stem: ® Cesspool(s) ❑ �Se 0fic Ta n...k....
El Tight Tank
El Other(describe):
4. Effluent Tee Filter present? 's�❑ Y ❑.M.Y"as' 3
• No If es, was it cleaned' .❑ No.
" 5. Condition of System ... .,... , �•—.. � � , »,"' ap .._. �'" � "�
.- ,
w-
' Mrr � u
6- System Pumped By: VIv
Nell.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents were disposed:
Lowell Waste Water
Sign a Haule Date
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